Sleep Apnea: Wake Up to the Problem

Better Sleep for Better Health

Dr. Erin E. Elliott

Awareness Diagnosis

FinancialsTreatment Financialswww.3d-dentists.com

Workflow Success

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Sleep 101

Understanding the diagnosis

Fatigue reversal and restoration

Memory Psychologic well-being

Biochemical refreshment

Immune function

Functions of SleepHow much sleep do you really need?

Age Sleep Needs

Newborns (0-2 months) 12-18 hours

Infants (3-11 months) 14-15 hours

Toddlers (1-3 years) 12-14 hours

Preschoolers (3-5 years) 11-13 hours

School-age children (5-10 years)10-11 hours (naps end around 6

years old)

Teens (10-17) 8.5-9.25 hours

Adults 7-8 hours

Study of 1.1 million men and women from 30-102 years old

Best survival was 7 hours of sleep

Increased mortality with >8 hours and <6 hours of sleep (15%)

Right Amount of Sleep?

7.7

Normal SleepArchitecture

Called a hypnogram

Mainly for BODY restoration

Neuronal rest and repair

Release of essential hormones for growth and recovery

Biologic Functionsof NREM Sleep

Mainly for BRAIN restoration Mood

Biologic Functionsof REM Sleep

Learning 20%Memory

The body is paralyzed

5% of sleep cycle

Transitional stage- 1-7 minutes duration

Easy to awake from

“Drowsy” stage Heart rate begins to slow

Stage 1 (N1)

Deeper stage of sleep with reduction in HR and BP, but still light

45-55% of total sleep time

Most body movements including bruxing

Stage 2 (N2)

Deep sleep or Delta sleep

Hormones and blood sugars regulate 20%

Restorative- growth and rejuvenation

Stage 3 (N3)

REM Sleep

Increase in heart rate, respiration, blood flow, BP

Apnea and hypopnea can increase

Dominates last third of night’s sleep

WHY??

Sympathetic nerves 2x more active as when awake

20%

Insomnia

Repeated difficulty with sleep initiation, duration, consolidation, or quality

10 types

More common in women

Caused by fear, stress, anxiety, medications, poor sleep habits, herbs, caffeine

Finding the cause is usually needed to cure it

Mayo Clinic finding: High correlation between insomnia patients failing pharmaceuticals and undiagnosed OSA

Sleep-RelatedBreathing Disorders

Disordered respiration during sleep

Obstructive Sleep Apnea

Central Sleep Apnea

Primary Snoring

——————->

Upper Airway Resistance Syndrome (UARS)

———————>

Cheyne-Stokes Respiration

Primary Snoring

40% of the population snores

Narrowing of the airway and vibration of the soft tissue

59% of people say their partner snores

With no arousal

25% of married couples are no longer sleeping in the same bedroom

Arousal = Going from a deeper stage of sleep to lighter stage- increased brain waves

Upper Airway ResistanceSyndrome (UARS)

Arousals associated with snoring but no accompanying oxygen desaturation

Arousals lead to sleep fragmentation/disruption and/or sleepiness

RERA’s- Respiratory Effort Related Arousals

Common in young female TMD patients

Central Sleep Apnea

OSA

Complete obstruction of the airway

Hypopnea

Obstructive Sleep Apnea AHIApnea-Hypopnea Index

5-15 mild- must show EDS with ESS15-30 moderate- green light

Apneas + Hypopneas/ # of hours slept

<5 normal- no coverage

>30 severe- CPAP intolerance

Must be >11!!!!!

Epworth Sleepiness Scale

MUST BE >11

CO-MORBIDITIES

EDS HISTORY OF ISCHEMIC HEART DISEASE

HISTORY OF STROKE

DOCUMENTED HYPERTENSION

DOCUMENTED SYMPTOMS OF IMPAIRED COGNITION, MOOD DISORDERS OR INSOMNIA

RDI

Respiratory Disturbance Index

Takes into account RERA’s

Apnea + Hypopnea + RERA’s/ number of hours slept

Oxygen Desaturation

ODI Nadir How much time was spent under 90%?

17-20% of adults have OSA

Up to 80-90% remain undiagnosed

More prevalent than diabetes or asthma

1 in 4 men and 1 in 10 women

50% over the age of 50

Epidemiology

Incidence become = in men and women at menopause age

Sequela: why should we treat this?

Stroke

Optometry

Heart Attacks Hypertension

Obesity

Impotence

Diabetes

Dementia

Periodontal Disease

Auto Accidents

Acid Reflux

Depression

Cancer

Obesity

Obesity is a dominant factor in only 60% of the cases of OSA

Twice as likely to die in men aged 30-70 with severe untreated OSA

Wisconsin Sleep Cohort

Sleep apnea raises risk of dying by 46%

Awareness

Financials

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Workflow Success Sleep disordered breathingThe dentist’s role in CREATING AWARENESS

Health History

Heart Disease

Glaucoma

Previous Strokes Depression

High Blood Pressure

Diabetes

Headaches

Fibromyalgia? Periodontal Disease

Acid Reflux/GERD

Add Questions

****Change Health History

Do you wear a C-PAP? or have you in the past? Have you been told to?

Do you snore or have you been told you snore?

Have you had a sleep study or been told to get a sleep study?

Have you been diagnosed with sleep apnea?

70% predictive of AHI >5

89% postive predictive of O2 desaturation >4%

ScallopedTongue

Crico-MentalSpace

Overbite

Crico-mental space <1.5mm

Overbite = Positive predictor value of 95% OSA

Pharyngeal grade 2 or greater

Lavigne et al; 2006 n= 13

OAT reduced bruxism by 42%

Bruxing

Kobayashi et al; 2002 n=20

Direct relationship between AHI severity and bruxism severity

MallampatiScore

Class I-IV American Academy of Sleep Medicine 2005

Presence or absence of OSA (Obstructive Sleep Apnea) must be determined before initiating treatment to diagnose and to provide a baseline

Sleep study and/or recommendation from MD

AASM Practice Parameters

STOP MAKING SNOREGUARDS!!!!Awareness Diagnosis

Financials

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Workflow Success PSG

Saves the insurance company money

Can have the patient “titrated”

An overnight PSG in which the patient is fitted with a C-PAP if they meet criteria

Patient only has to come to the lab once

Split-Night Study

Types II, III, and IV

Must have a Type II or III to be covered by medical insurance

Dependent on how many channels

HST (Home sleep studies)

Can get false negatives

Used often because cheap and accessible

Considered a Type IV device

Only measures pulse and oxygen

Pulse-Oximetry

Accurately predict who and how to treat Awareness Diagnosis

Financials

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Workflow Success

Consult- exam 9920X, 3D CBCT 70486/ 76376

Delivery- E0486 (preauth) (physician)

F/U exam 9921X

HST- 95806 (preauth)

Records- N/A

All you need to know

HST- 95806 (preauth)

You will need1) Medical claim form printing- CMS 1500 as a paper claim or electronic claim- Cannot be hand-written

2) ICD diagnosis code made by a physician from the sleep study

3) The sleep study with the diagnosis of OSA from a sleep MD

4) CPT codes (E0486, exam codes, etc)

5) SOAP reports and narratives that the patient was seen by you and is an appropriate candidate for OAT

6) C-PAP Intolerance Form

7) An order (or prescription) for the oral appliance signed by a physician or healthcare provider (MD, DO, ARNP, PA-C)

Awareness Diagnosis

Financials

Treatment Financialswww.3d-dentists.com

Workflow Success Treatment Options

Lifestyle Modifications

Oral Appliance

Positional Therapy Sleep Hygiene

Pharmacological Treatment

Surgery C-PAP

Sleep Hygiene

Avoid big meals No dogs/ pets

Hot shower to cold, dark room

No electronics

7.7 hours of sleep Early to bed, early to rise- same routine every night

Sinus rinses Falls short of being primary treatment

Flonase Nasonex

Pharmacological Treatment

Compliance rate reported as 40-80%*

Continuous Positive Airway Pressure

Different types of masks, tubes, and machines

C-PAP

OAT (Oral appliance therapy)

Practice Parameters

AASM 2006

Sleep study and/or recommendation from an M.D.

Presence or absence of OSA must be determined before initiating treatment to diagnose and to provide a baseline

Practice Parameters

Should be fitted by qualified dental personnel

Trained and experienced in the overall care of oral health, the TMJ, dental occlusion and associated oral structures

Management of patients should be overseen by practitioners who have undertaken serious training in sleep medicine with focused emphasis on the proper protocol for diagnosis, treatment, and follow-up

Practice Parameters-Treatment Objectives

Primary snoring with no OSA

OSA Resolution of clinical signs and symptoms

Normalization of AHI (<5) oxyhemoglobin saturation

Treat snoring to subjectively acceptable level

Practice Parameters

C-PAP is a gold standard

Mild to moderate OSA

Are not appropriate candidates for C-PAP

When patients prefer MADs to C-PAP (new recommendation)

Who do not respond to C-PAP

Fail treatment attempts with C-PAP, weight loss or sleep position change

MAD’s have a more limited use in severe OSA and high BMI

Practice ParametersFollow-upNot indicated in primary snoring

Follow-up PSG with oral appliance in place after final adjustments have been made

Changed to include mild OSA due to data that shows even low AHI is associated with adverse health outcomes

Practice ParametersFollow-upPatients must return for follow-up visits with dentist

Must return to referring physician to assess signs and symptoms of worsening OSA

Compliance, Fit, Occlusion, Patient Alteration

Published in July 2015:

“In the first official joint guideline from the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM), oral appliance therapy is recommended for the treatment of adult patients with obstructive sleep apnea (OSA) who are intolerant of continuous positive airway pressure (CPAP) therapy or prefer alternate therapy.”

New Practice Parameters Effectiveness Studies Effective Treatment Oral Appliance C-PAP

Total Population(n=103)

76.5% (39/51)56.9% (29/51)

82.7% (43/52)76.9% (40/52)

Non-severe OSA(n=50)

84% (21/25)84%(21/25)

80% (20/25)80% (20/25)

Severe OSA(n=53)

69.2% (18/26)30.8% (8/26)

85.2% (23/27)74.1% (20/27)

AHI <5 or decrease of 50% and <20 from baseline in a patient with no symptoms

AHI < 5

Good for mild to moderate

Respiration (October 2010)

Conclusion: “There is no clinically relevant difference between MAD and CPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively.”

Effectiveness

Disease Alleviation

FinalOption

Tracheostomy

Oral AppliancesWhat Do I Choose?

Conclusion: A custom-made device turned out to be more effective than a thermoplastic device in the treatment of SBD. Results suggest that the thermoplastic device can’t be recommended as a therapeutic option nor can it be used as a screening tool to find a good candidate for mandibular advancement therapy. [Bold added]

Am J Respir Crit Care Med. 2008 Jul 15

EMA Silent-nite TAP-3 and TAP-3 Elite

Two liners available- Thermacryl and Durasoft

Dream TAP

Herbst

SUAD

Dorsal Fin

Edentulous

Classic (hard acrylic) vs. Flex

DE (Discluding Element) ramp option

Cover distal of mandibular 2nd molars

Elastic hooks- I put on all appliances

Anterior opening option

Acrylic Appliances

Metal reinforcement

Prosomnus (Prosomnus lab only) Optisleep- Sicat Approach:• Can I make a Optisleep? (have the technology, posterior teeth and retention)

• Can I make a Prosomnus?

• Select if small mouth/female, otherwise IA

• Add DE if they are a clencher

• Do I need to make a Herbst (Prosomnus PH)?

• side to side wear pattern

• or insurance mandates

• Somnomed Fusion w Flex liner (dorsal fin) if all else fails

• Great for edentulous areas

• SUAD or SUE- big, strong bruxers that break everything

Prosomnus (IA, CA, PH, Select)- Prosomnus

sjacobsen@prosomnus.com

Sirona- Optisleep

Somnomed- SUAD and Dorsal Finjsaenz@somnomed.com

LabsProtocols

Maybe even someone who struggles with OSA

Trained to do consults, deliveries, adjustments, medical insurance, follow-ups, HST

Financial arrangements

Dental Sleep Medicine Champions

All coordination Someone who has passion and loves to learn

They need help

Works with appeals and denials

Financial arrangements

Track medical insurance payments

Tracks down referrals

Eligibility checks, pre-auths, and submit claims

Scheduling

Consult without sleep study- 4 units

One- Three week check- 3 units- Assistant time

Delivery- 3 units- Assistant time

Consult w/ sleep study & Impressions- 9 units

Impressions- 4 units

Scheduling

One month check- 3 units- Assistant time

Annual check- 3 units- Assistant time

3/6 month check- 3 units- Assistant time

Reviewing Sleep Study

Review AHI or RDI

apneas vs. hypopneas

supine vs. non-supine

Reviewing Sleep Study

Oxygen level

how long <90%?

Nadir

Reviewing Sleep Study

Snoring

Sleep efficiency- “Doc, I didn’t sleep at all”

Sleep stages- any REM?

PLM

Better Candidate

Low BMI

No nasal obstructions

Female CPAP pressure under 10.5

Retrognathic

Positional OSA

Big ROM

Younger More hypopneas vs. apneas

Shallow MP angle

Initial Paperwork

Sample oral appliances

Discussion of their CC and sleep study

Overview of OSA

Treatment options

Consult

Doctor exam- including discussion of previous history

Previous History

Surgeries

Previous oral appliances?

Previous TMJ

Previous sleep studies

C-PAP experience

Patient History

Hours of sleep a night

Exercise Habits

Caffeine Intake

Morning headaches

Dry Mouth

Alcohol Intake

Full Exam

Vital signs- BP and Height and Weight

TMJ- Clinical, palpation, stethoscope

Tooth exam Neck size

Tongue

Periodontal disease Occlusion and Orthodontic Class

Range of Motion

Soft palate and uvula

Jaw relationship

Malampatti score

Nasal exam- Narrow nares? Large turbinates? Septal deviation? Occluded? Mouth breather?

Full Exam

Cottle Maneuver:

If it’s easier, then it is a valve issue. There are no good surgical treatment for this Patient is a good candidate for MUTE

www.breathright.com

www.mutesnoring.com

www.maxairnosecones.com

Nasal Breathing

MUTESNORING.COM/DRELLIOTT

Skeletal and dental classifications

Cone Beam

Location and severity of airway obstructions

Nasal passageways and sinuses

Oral Maxillofacial pathology

Paperwork If no sleep study?

Refer directly to sleep lab for PSG or HSAT

Third party service

Refer to MD

Get diagnosis from a board certified sleep physician

You will need1) Medical claim form printing- CMS 1500 as a paper claim or electronic claim- Cannot be hand-written

2) ICD diagnosis code made by a physician from the sleep study (G47.33)

3) The sleep study with the diagnosis of OSA

4) CPT codes (E0486, exam codes, etc)

5) SOAP reports and narratives that the patient was seen by you and is an appropriate candidate for OAT

6) C-PAP Intolerance Form

7) An order (or prescription) for the oral appliance signed by a physician or healthcare provider (MD, DO, ARNP, PA-C)

What You Will Need:

• Impressions

• Putty/ Wash

• Digital

• Bite

Soak prior to arrival (ONLY IF ACRYLIC)

Check occlusion

Discuss morning exercises and make “chew toy”

Have patient lay back or sit upright in chair with it in for 5 minutes

Adjust- Occlude or Hydent (white) spray

Appointment 3: Delivery Delivery

Go over informed consent again (meaning discuss there may be TMJ pain and a different bite in the morning)

Show the patient how to advance if you feel they can handle it

Instructions

Prodent Clean

WWW.PRODENTCLEAN.COM

Proof of delivery

MorningExercises

“When you wore it, how did it fit?”

Questionnaire Adjustments/try it in

BP/Pulse Epworth

One/two week check

Show them how to advance/ calibrate

BP/Pulse

Experience? Consider calibration HST

Epworth Questionnaire

One-month check

Try to get rid of them (IN THE NICEST WAY POSSIBLE)

BP/Pulse

Build value into these appointments

Consider possible calibration check with HST

Epworth Questionnaire

Three/six -month check

Release on an annual basis

Letter to Physician and copy of HST report

Request for follow-up PSG

Success?

BP/Pulse

Questionnaire/Epworth

Adjustments? Fit? Comfort? Compliance?

CLEAN THE APPLIANCE/Try in

Annual check

SLEEP STUDY

Initial Contact NP Intake Form Medical Insurance Eligibility / Benefit Check

NO Give Medical Biller a

Medical Billing Slip & Write HST Preauth on it

YES Have Pt sign Records

Release Obtain Copy of Sleep

Study no more than 7 years old!

Records CPAP Intolerance Form Records U/L Bite 3D XRay W/ Bite OSA Treatment Consent Medical Billing Slip write “Pre-Auth for

Appliance Delivery Deliver Appliance - Home Care

Instructions Proof of Delivery - AM Aligner Medical Billing Slip - Letter to Pt MD

1 Month Follow Up Adjustment Form Medical Billing Slip Follow Up HST Letter to PT MD

1 Week Follow Up Adjustment Form Medical Billing Slip Letter to PT MD

Initial Consult / HST HST Demo HST Release Form Collect $100 for HST

Sleep Consult / With Sleep Study

Review Sleep Study Test Results

SLEEP CONSULTS Sleep Questions 3D XRay / Air

Segment Photos Review Appliances Go Over Patient

Financial Resp. Letter to PT MD Physician Order Epworth Sleepiness

Scale

HST Review Review

Results Letter to Pt

MD

4 Month Follow Up Adjustment Form Medical Billing Slip Letter to PT MD

6 Step Action Plan:

• #1- Change Health History

• Do you snore? Or have you been told you snore?

• Do you wear a CPAP? Have you in the past? Or have you been told to get one?

• Have you had a sleep study? Or have you been told to get one?

6 Step Action Plan:

• #2- Put Evaluator in each operatory

• Scalloped tongue

• Small airway

• Bruxing/ Wear

• Acid Reflux

6 Step Action Plan:

• #3- Medical Insurance

• Collect cards on EVERY patient

• AND DRIVER’S LICENSE!

• Learn how to do EC (Eligibility Checks)

• Sign up with 3rd party biller

6 Step Action Plan: • #4- Morning Huddle Identification

• Did they check any of the questions?

• Previous nightguards

• Health history

• Hypertension

• Psych meds

• Acid Reflux

• Diabetes

6 Step Action Plan:

• #5- Photos

• Bruxing Wear

• Airway

• 3D

6 Step Action Plan:

• #6- Start talking to patients and get more in depth training

www.joinsleep101.com

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